Saturday, March 10, 2012

Dermoneuromodulation: Neurodynamics, tunnel syndromes, cutaneous nerves.

Peripheral neurodynamics

In 1998 I attended David Butler's "Neuromobilization" workshop. I must admit, I was not orthopedic-y enough to be about to translate everything he was teaching into a "spine-out" logical flow. I admit to always having been an outside-in sort of interactor therapist, both physical and manual. I was called on the rug during clinical training for thinking it made sense to work with stroke patients by working with their hands first instead of their trunks. But's that's a whole other story.
Michael Shacklock, another ortho person turned neurodynamic guy, was dedicated enough to bring back to life the original book by Alf Brieg, Adverse Mechanical Tension in the Nervous System. (It's mostly about spinal cord neurodynamics, of more interest to ortho-types of manual therapists, deep into structuralism, steeped by it, than it is to me, who has always stayed more outside the spine, conceptually and operatively. I prefer to affect the nervous system from its sensitive surface membrane, also ectodermal in origin, i.e., the epidermis and related exteroceptive and interoceptive capacity of its many sensory endings.)

Yet, as I sat in Butler's class, I felt my manual therapy worldview cave in - everything he said in terms of nerves, what they were about, how nociception became established, then amplified inside them, inside the system itself, made such sense it took me over completely, and I've been a nerve girl ever since, never gave "tissue" a second thought after that, especially fascia. Everything he said was congruent with another body of knowledge I had examined, embryologic development. You know those pictures that fool the brain into seeing two things at the same time, and you think you see it one way, but suddenly it looks like something else entirely?
That was me. I hadn't seen the rabbit for looking at what I thought was the duck. Abruptly, I graduated from what I call my "mesoderm" phase, and plunged headlong into an "ectoderm" phase from which I'll never emerge. Because at least now we're talking about the right kind of 'tissue' -  skin, nerve, neural container, spinal cord and brain - all direct derivatives from ectoderm, all concerned with "management" of an organism. Not structural space-filler/moveable puppet part and their glued-together connectedness (bone, joint, muscle, tendon, ligament, fascia). It's all a lot more complex than this, of course, with different parts of the nervous system doing different jobs, and different parts of the brain running various subsystems of visceral afferent/efferent function, autonomic function and so on, but at least now, we no longer need to entertain the crazy idea that innocent tissue "causes" anything like "pain" or try to prove somehow that there is any sort of correlation between what we might do with our hands, when working with people, and any sort of pain reduction, based on having magically affected some sort of deeply buried "structure" with some goofy operator model of treatment, whether vitalistic or structuralist - that dualistic Descartes combination. It's about nervous systems interacting with each other, and stress reduction. How simple is that?

In 2007 I was fortunate enough to gain access to an anatomy lab and dissect out cutaneous nerves, which were the ones that interested me! They have feelings too. In live people that is. Michael Shacklock published a few of the photos in his newsletter. I wrote up a paper about it that is yet to be published somewhere. But, at least, it's now been done, and I figure, pulling gently on these little rami likely has some sort of beneficial effect on intrinsic circulation well up into the nerve they are part of, all the way up to the first synapse (neurologically) or into the dorsal root ganglia, maybe (physically, mechanically), especially if you handle body parts simultaneously, and make treatment stress free for the patient by eliminating gravity as much as possible.

Which brings us to the topic of tunnel syndromes.

I think that covers the topics on the right side of the dermoneuromodulation diagram, under "physicality".  These are the considerations I have while treating as a manual therapist. I'm still "operator" model enough to need to think about something physical as I treat. I'm not zen enough to be completely content-free, pure interactor.  Not yet anyway. But I'm a lot less "physical" and a lot more "therapist" than I was, once upon a time.

1. Michael Shacklock Clinical Neurodynamics
2. Dermoneuromodulation treatment manual (first draft) Diane Jacobs

1. Dermoneuromodulation (diagram, gearing up)

2. Dermoneuromodulation: Where it came from

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